Case Study: Pinellas County, Fla.

Pinellas County has a long history of using data from across systems to understand the characteristics of people who use services, what puts them at risk for an escalation in their service needs and how it can improve service delivery. Due to limited state funding for behavioral health and the high cost of frequent utilizers on systems, Pinellas County is prioritizing stabilizing these individuals. In addition to working to reduce wait times for receiving behavioral health services, determining gaps in the continuum of care and developing solutions that meet the needs of the community, Pinellas County created the Pinellas County Empowerment Team (PCET) to assist people who have mental illnesses and substance use disorders access and receive care that will reduce recidivism and improve and support well-being.

Pinellas County Empowerment Team

Pinellas County established the PCET in May 2015. Its purpose is to identify the most frequent utilizers of the county’s crisis stabilization unit (CSU) and jail and provide an intensive level of treatment and services that will break the cycle of crisis and eventually
reduce the need for interventions by helping people improve their health and well-being. Under state law, the CSU receives and evaluates people who are a danger to themselves or others.

The county initially identified the top 30 highest users of the CSU and jail for planning and research purposes. Identifying this first cohort allowed the county to develop a better understanding of the population and its needs. Paranoid schizophrenia, bipolar disorder and schizoaffective disorder are common diagnoses. In addition to mental illnesses and substance use disorders, childhood trauma, victimization and homelessness are also very common within this population. Through this match of behavioral health and justice data, the project helped the county realize that it was spending more than $2 million on these 30 people.

Taking what it learned from its research on the top 30 frequent utilizers, the county was ready to implement a PCET pilot project. It identified a new top 30 cohort with a target population that includes not only the most frequent users of the CSU but also people who are most frequently referred from the county jail to CSU. The project leverages existing services and depends on a new network of personnel, including a case manager, psychiatrist, therapist, licensed practical nurse (LPN) and law enforcement officer to optimize the delivery of care. Because coordination and a commitment to client engagement are at the heart of the pilot, the strategy is intended to be a more cost-efficient approach to meeting the needs of the top 30. The Board of County Commissioners provided $964,442 to support PCET, which covers personnel and other operational costs, and is a 62 percent reduction in what the county was paying for the first top 30 cohort it researched.

PCET depends on repeated and frequent engagement with participants to build trust. Symptoms of medical conditions such as  schizophrenia can make the process of developing trust even more challenging. The key is to make people understand that there is a case worker who can help them when they are ready, along with good customer service, including warm connections to providers, to keep  people engaged.

The pilot is aligned with the county’s motto, “With partners, we do more,” as it emphasizes the importance of  collaboration to meet the needs of frequent utilizers, bridge gaps in resources and build the continuum of care. Partners include hospitals, homeless shelters and housing providers, the public defender’s office, law enforcement, advocacy groups and behavioral health treatment and service providers. These partners meet on a regular basis to discuss how the pilot is operating, including challenges, progress and strategies to improve the system of care.

Outcomes & Next Steps

Pinellas County contracted with the University of South Florida’s Florida Mental Health Institute to evaluate the PCET pilot project. The county is interested in the effect of the project on reducing utilization rates of the CSU, jail, detox and hospitalization. It also wants to take a qualitative approach to examining the results of the pilot, including collecting staff and participants’ perceptions of what was successful and where there were barriers.

Preliminary data indicate that PCET is effectively connecting the top 30 in the pilot to services and into treatment plans. Since participants enter the pilot on a rolling basis as they are located and engaged, the baseline measures account for these individual differences. Additionally, outcome measures are based on one full year of participation, which varies for each person. The comparisons span from July 2015 to December 2017.

Eleven of the participants had no CSU visits within the year following their entry into the pilot. The Pinellas County Sheriff’s Office reported that there were fewer arrests and less severe offenses for the top 30, and jail bed days have been reduced by almost half from 1,816 days to 968 days. In addition, county jail costs went from a total of $227,000 to $108,125. The cost of Medicaid-covered services decreased from a total of $534,456 to $216,452, and emergency room visit costs from around $30,000 to slightly more than $15,000. Eight-two percent of the participants who were homeless at entry into the pilot have been housed. By working with partners to leverage existing resources and provide intensive case management, only 69 percent of the funding allocated by the Board of Commissioners for PCET was expended during year one.

For the second year of the project, the county will focus on developing and implementing solutions to challenges it has identified with how services are coordinated. The county is also working towards creating a transition plan for those individuals that are ready to move out of intensive case management.

In collaboration with the Stepping Up initiative, the Data-Driven Justice initiative and the John D. and Catherine T. MacArthur  Foundation’s Safety and Justice Challenge, the Substance Abuse and Mental Health Services Administration (SAMHSA) convened a
Best Practices Implementation Academy to Reduce the Number of People with Mental Illnesses and Substance Use Disorders in Jails (BPIA) in April 2018 in Alexandria, Va. At the BPIA, delegations from 24 jurisdictions involved in one or more of the three initiatives met to showcase best practice strategies and advance implementation efforts to prevent or reduce the jail involvement of individuals with mental illnesses and substance use disorders.

This case study is part of a series highlighting the six counties that constituted the “Best Practices” teams representing the Data-Driven Justice initiative and the Stepping Up initiative at the BPIA.

SAMHSA contracted with Policy Research Associates (PRA), which operates SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation, to facilitate the BPIA. Additional partners included the lead organizations of the Stepping Up initiative (the National Association of Counties, the American Psychiatric Association Foundation and The Council of State Governments Justice Center), the Data-Driven Justice initiative (the National Association of Counties and the Laura and John Arnold Foundation) and the John D. and Catherine T. MacArthur Foundation’s Safety and Justice Challenge.